1. PICO Deep brain stimulation for treatment resistant depression. Clinical reality ?

2. Deep brain stimulation in the treatment of depression. Acta Psychiatr Scand, 2011 Blomstedt P et al.

3. Subcal.cing. gyrus (no 20) 85% had ECT HDRS - 52% / 1 year 35% remission Capsula interna (no 15) 100% had ECT HDRS -44% / 1 year 40% remission Nucleus accumbens (no 10) 100% had ECT HDRS - 36% / 1 year 30% remission

4.  Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment- Resistant Depression  Biological Psychiatry, 2008  Lozano, et al

5. Increased activity in the subcallosal cingulate gyrus

6.  Pharmacotherapy  Transcranial magnetic stimulation  Electroconvulsive therapy Altered activity of the SCG  Deep brain stimulation Direct modulation of the SCG

7. Inclusion Severe Chronic Treatment resistant Failure to respond to a minimum of four different treatments  Antidepressant pharmacotherapy of sufficient dose and duration  Evidence-based psychotherapy  Electroconvulsive therapy

8. Exclusion  comorbid Axis I psychiatric conditions,  Axis II cluster B diagnosis  suicidal behaviour within the past year  concurrent neurological or medical conditions that could interfere with the treatment.

9. Subjects (n = 20) Male/female9/11 Age at Enrollment (years)47.4 ± 10.4 Age of Onset of MDD (years)27.1 ± 8.3 Length of Current Episode (years)6.9 ± 5.6 Number of Lifetime MDE (n)3.9 ± 3.1 Received ECT (n)17/20 Baseline HRSD-1724.4 ± 3.5 3 patients received no ECT before DST All patients received medication during DST

12. Adverse EffectNumber of Patients Wound Infection and Hardware removal3 Reinsertion of DBS Hardware1 Wound Infection Managed with Antibiotics Alone1 Perioperative Seizure1 Worsening Mood/Irritability2 Perioperative Headache4 Pain at Pulse Generator Site1 No Adverse Effects7

13.  Deep Brain Stimulation for Treatment-Resistant Depression: Follow-Up After 3 to 6 Years  Kennedy, et al.  Am J Psychiatry, 2011

14. 1 unrelated death 2 suicides 2 lost to follow up 3 devices removed

17. Argument in favour  Otherwise intractable depression  Remission rates around 30 %  Possible long term benefits

18. Arguments against  No clear target-area  Invasive procedure  Battery life  Open label assessment  Small N  Concurrent medication use

19. In conclusion  Experimental therapy  Clinical studies  Multidisciplinary teams